If any prior marriages, list dates, places of termination, and
any continuing support obligations.

II. BENEFICIARY INFORMATION

Spouse:
Date and Place of Birth & Citizenship

Does your spouse, any child or any grandchild have a physical, mental or
emotional disability?
YesNo
If Yes, please explain the individual’s special needs.

Does your spouse, any child or any grandchild have special financial needs?
YesNo

III. EXECUTORS, TRUSTEES AND GUARDIANS

If you have decided, we need your preliminary answers to the following
questions:

A.You must decide who the Executor and Successor Executor of your Estate will
be.

Executor:

Successor Executor:

B.A child under 18 years of age must have a Guardian. Who will care for that
child if both spouses are deceased. You also need to name a Successor Guardian.

Guardian:

Successor Guardian:

C.Who is to be the Individual Trustee of Trusts created by your Will? (The
Guardian of your Estate named above may also be the Individual Trustee of any
Trust you create.) We also need your choice for Successor Individual Trustee.

Trustee:

Successor Trustee:

IV. INDIVIDUAL BEQUESTS

You need to identify in your estate plan if you intend to bequeath any real
property, cash, or other item(s) to any individual, church, school, or other
charitable organization.

V. OTHER ESTATE PLANNING DOCUMENTS

A. Health Care Power of Attorney

We recommend that you have a “Health Care Power of Attorney”
prepared, whereby you would appoint an Attorney-in-Fact, who can be a relative
or friend, to make decisions regarding medical treatment on your behalf in the
event you were unable to do so (i.e., comatose or otherwise incompetent or
deemed incapable of making decisions on your behalf).

Attorney-in-Fact:

Alternate Attorney-in-Fact:

B. Durable Power of Attorney

We recommend that you have a “Durable Power of Attorney”
prepared, whereby you would appoint an Agent to handle your property and
affairs. This Power of Attorney would survive your disability or incapacity. As
with the Health Care Power of Attorney, you should choose an Attorney-in-Fact
and Alternate which do not have to be the same people chosen as your Health Care
Power of Attorney-in-Fact.

Attorney-in-Fact:

Alternate Attorney-in-Fact:

VI. MISCELLANEOUS

In connection with preparing answers to this Questionnaire, you
may have questions which have not previously been answered. If that is the
case, please list them below and on an additional sheet (if necessary):

The materials included in this website are for general informational purposes only and do not constitute legal advice. Information contained herein is not intended to create and does not constitute an attorney-client relationship. You should seek advise from professional legal counsel. Please be advised the submittal of a reply to the online estate planning survey does not constitute a contractual relationship between the Law Firm and yourself and does not represent a binding legal obligation for the Law Firm to represent you in any administrative or court proceeding. Finally, submittal of a reply to an estate planning survey does not satisfy the requirements for a legal Will or other legal instrument under the law.